3. Presentation of the research
3.2 Context of the research
3.2.1 The educational track of Assistant en Soins et Santé Communautaire (ASSC)
184.108.40.206 Introduction to the profession of ASSC
The profession of Assistant en Soins et Santé Communautaire (ASSC), that we have translated in Social and Health Care Assistant, is a relatively new professional role in Switzerland. This educational track was established some years ago (2002 for the school-based training, with the first graduation in 2005, and 2009 for the Dual system, with the first graduation in 2012) to recruit more healthcare professionals, in consideration of the severe shortage of professionals working in this domain currently experienced in Switzerland (Schweri & Trede, 2010).
Social and Health Care Assistants are supposed to assist and take care of people of all age in case of sickness or on a regular basis, in their everyday life. They are supposed to organise the physical and social environment of their patients/clients, while at the same time providing physical assistance to them, on the basis of their needs. More precisely, they are asked to work on a number of professional axes, going from 1) assistance and care; to 2) conception of the physical environment and organisation of everyday activities; 3) administration and logistics; and finally 4) medico-technical procedures. In particular, in relation to this last point, ASSC are prepared to perform medico-technical procedures under the direct responsibility of nurses and medical staff of the institution in which they operate. In this sense, ASSCs need to work on a regular basis in multi-disciplinary teams.
Health Care Assistants can work in a number of different institutions, as virtually any setting in which health professionals are needed may profit from the presence of this professional role. For this reason, the profession can assume very different characteristics, adjusting to the target audience, the constraints, and challenges of the various settings. A non-exhaustive list of the professional setting in which ASSC can be hired would include retirement homes for elderly people, the hospital setting, in a number of different wards as psychiatric or emergency, and to the home care service for which they need to go to their patients’ habitations. As one can easily imagine, the tasks, responsibilities and situations faced by assistants working in their patients’ home are not the same as the ones encountered in emergency wards of the hospital. In the first case the maintenance and care of the physical environment of the patient, including for example the basic cleaning service, may be particularly frequent, while in the hospital setting assistants will be asked to perform more medico-technical procedures. The variety of the tasks associated with this profession represents an important characteristic and sometimes a challenge for the
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66 professionals in this role, and can be even more critical for learners in this educational path. In this sense, it is very important for them, to have the opportunity of discussing and learning from one another about this great variety of working conditions, associated with the possibility of experiencing various workplaces through internships.
On the basis of the characteristics of the professional roles of ASSC, some personal characteristics are required to the ones interested in this education path, going from their desire and willingness to help and assist others, to the understanding of others. Additionally, a certain psychological and emotional equilibrium is also required. Assistants also have to be able to work in teams, to act with discretion, and to be flexible in adjusting to irregular schedules and night shifts.
220.127.116.11 A profession in between, specificities of ASSC and their professional role
When presenting the profession of Social and Health Care Assistants, it is very important to describe also its relationship and positioning with respect to the other healthcare professions sharing similar, or sometimes the same, tasks. In this sense, it is important to mention the fact that ASSC profession is often described, by its very professionals and even the teachers, as a profession in between other two: health aid (aide soignant) and nurse. More precisely, as the health aids, ASSC have to perform a series of tasks aiming at the well-being of the patients, as washing them, taking care of their environment and also accompanying and supporting them in critical moments. On the other hand, in comparison to health aids, ASSC are prepared to execute more technical procedures, allowing them for a more complete care of the patients. The task of washing them can be complemented by, for example, the replacement of their caterer. Additionally, they are allowed to administer the pills and some medications to their patients, under the surveillance and responsibility of nurses or medical staff. In this sense, the profession of ASSC is also similar to the one of nurse, even if more limited in terms of the tasks and procedures that can be executed.
This positioning of the profession in between other two, associated with the fact that it is a relatively new role, have an important impact on how this is perceived by the colleagues and on the actual tasks and responsibilities imparted to these assistants in the different institutions. More precisely, two main effects of this situation may be observed: in the first place, an often confronting and difficult relationship with health aids and nurses have been reported. According to many sources of information as professional association, learners (see for example the interviews discussed later in this chapter), the teachers of the professional school, and the same episodes reported by apprentices, both nurses and health aids sometimes manifest an opposing attitude towards ASSC as they consider that their own role may be less valued or risks to be modified in reason of the presence of these new professionals. This creates a sometimes difficult working environment in which ASSC struggle to be fully integrated and accepted by the colleagues with whom they are required to collaborate. Many learners reported encountering confrontational behaviour of others and struggling in making them accepted by the others.
67 Additionally, a second effect of this situation is associated with a certain fuzziness surrounding the specific tasks and responsibilities that ASSC are prepared to face. In this sense, in some institutions assistants may be asked to perform procedures they are not prepared and allowed to perform. On the other hand and probably more often, in other institutions, in order to avoid any risk, ASSC are not working to their full potential, being relegated to less responsibilities that they could actually undertake. Both these situations may be particularly critical for apprentices in their internships, as they risk to be asked to perform tasks above their competence and legal possibilities, or, on the other hand, not be allowed to learn and exercise some of the procedures required to them in order to complete their education and that will be requested in their future working environments.
In this sense, in order to better prepare learners to the various working situations they may face, and provide them with an environment where to share and discuss the situations encountered in the workplace, we believe that it is important to give learners the opportunity of sharing and discussing their experiences in terms of the relationship with the other professionals in their working environment, and of discussing about the tasks and responsibilities attributed to them. Having a better overview of what their colleagues are asked to do in different working environments and discussing this with the teachers, will provide them with the possibility of negotiating their workplace situation and making sure they are invested of all the opportunities and requirements associated with their role.
18.104.22.168 Professional identity in the health domain
In reason of the fuzziness associated with the specific characteristics of the ASSC profession, the construction and development of a professional identity may reveal particularly complex for apprentices in this vocational education path. As seen in the literature review of this manuscript, one of the most important steps implied in the development of apprentices’ professional identity is associated with their integration of a professional community, characterised by the progressive acquisition of the practices and the customs of the profession (Lave & Wenger, 1991). This movement from a more peripheral to a more central participation in this community may reveal particularly difficult when learners do not have a well-defined professional group to which they can refer, as is the case for ASSC. Moreover, another issue comporting an additional complexity to this process, is that as ASSC are required to perform different tasks in different working environments, the community of practice resulting from these profession is very heterogeneous and new comers can sometimes struggle in recognizing themselves in this group.
On the other hand, the health sector represents one of the fields in which the development of professional identity has been particularly investigated and researched. A number of studies have observed how this identity develops overtime in all professional groups of this domain, going from doctors to nurses, from radiologist and physiotherapist to health aids. Professional identity has been defined as the series of knowledge, values, attitudes and skills shared by members of one professional group (Worthington, Salamonson, Weaver, & Cleary, 2013). This definition confirms the importance, key for the design of our
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68 study, of the two vocational learning settings (school and the workplace) and the knowledge they impart, as knowledge, skills and attitude all concur in the construction of this identity. The professional identity can have an impact on the way people interact and create professional groups differentiating themselves from others (Adams, Hean, Sturgis & Macleod Clark, 2006; Crossley and Vivekananda-Schmidt, 2009).
Confirming our idea about the major importance of both theory and practice, Cook, Gilmer, & Bess (2003) assert that theoretical as well as clinical components contribute to the development of this identity, impacting on the success of the transition from the student to the professional status of nurses. In this sense, a low professional identity can result in the decision of nursing students of leaving the program or, subsequently, the profession (Worthington et al., 2013; Deppoliti, 2008). Skorikov & Vondracek (2011) added that occupational identity, defined as the awareness of oneself as a worker, represents an important factor determining “occupational success, social adaptation and psychological well-being” (p.693).
Adams et al. (2006) explored the factors influencing the development of professional identity in health and social care professions and identified a number of different aspects: as for example the gender; the specific profession people are members of (professional identity of nurses is different from the one of doctors); previous experience in the health sector; attitude towards team work; knowledge of the profession; and cognitive flexibility.
Coster and colleagues (2008) conducted a study aiming at observing the development of professional identity in students enrolling in different health careers (dentistry, dietetics, medicine, midwifery, nursing, occupational therapy, pharmacy, and physiotherapy) in the UK. The professional identity was measured using Brown et al.’s (1986) scale, based on three main factors: the awareness of group membership, the emotional significance of this membership, and the values attached to belonging to the group. The results of this research highlighted how professional identity for all professional roles was high on entry in the healthcare education (as asserted by Mandy, Milton, & Mandy, 2004), but slowly declined overtime (similarly to what was shown above for self-efficacy beliefs). The authors suggest that this may be explained by the fact that learners acquire awareness about their professional status, and become less enthusiastic about it after the clinical practice.
Globally, these studies are extremely relevant for the context of our research, as they confirm the need for a support in the construction of learners’ identity, so that apprentices can positively integrate the profession, lower their risk of withdrawing the professional course and prepare to interact more effectively with other professionals. The aim of our research is therefore to support learners in this process.
22.214.171.124 Reflective practice in the health domain
Health and social care field presents another interesting characteristic, making it a particularly suitable environment to conduct a research on apprentices’ professional development, which is associated with the use of reflective practice and of writing activities. Even though we do not aim at presenting here an
69 exhaustive review of all types of reflective activities conducted in this educational domain, it is important to mention the fact that the health profession, as nursing education to mention one example, have a well documented tradition associated with the use of reflective tasks. Just to cite a few, critical incidents techniques, as well as portfolios and learning journals have been largely implemented in this field, producing interesting results. Additionally, as seen in our literature review various asynchronous discussion environments facilitating the creation of communities of practice in the health care domain have been successfully implemented.
The critical incident technique (Flanagan, 1954) is a technique aiming at the collection of a series of important facts concerning the behaviour adopted in certain situations. This technique is not characterized by a set of precise rules, but rather is an adaptable method that can be modelled and shaped in order to meet the demands and constraints associated with one specific situation. The concept of critical incidents should not be interpreted in a narrow sense, as significant situation, selected on a number of parameters, can be considered as critical incidents. In this sense, not only negative circumstances should be included when using this technique but all meaningful episodes. As mentioned above, this technique has been thoroughly implemented in the field of health care and particularly nursing education (see Byrne, 2001;
Redfern & Norman, 1999; Minghella & Benson, 1995, only to cite a few examples), to the point that Schluter et al. (2008) provided a guide dedicated to the implementation of this technique in this specific context. They mention in particular three key elements for the success of this technique: 1) participants should complete a detailed description of one situation; 2) the actions of the people involved in the situations should be reported in details; and 3) the outcome of the event should be also discussed in details. Thanks to these three steps, this technique can reveal particularly useful to discuss about the possible reactions to a difficult situation lived in a sensitive environment as the one of health and social care.
Porfolios and learning journals have also been particularly exploited in the field of nursing education and health care in general. As mentioned in the literature review of this thesis, learning journals were implemented in various studies showing a positive effect on the metacognitive skills of learners (e.g.
McCrindle & Christensen, 1996). Gillis (2001) discussing about the usefulness of journal writing in nursing education cites Bunkers (2000), who defined these journals as tools that provide an opportunity for apprentices to describe, interpret and analyze their learning experience and consider their future perspectives. This activity would therefore support the development of higher level conceptual skills, through the use of three skills: introspection, reflection and dialogue. In this sense, the authors considers that the use of learning journals represent a unique opportunity to externalise and elaborate what happens in practice, which is otherwise very difficult to integrate, explore and connect with knowledge and ideas.
This activity could, therefore, provide an opportunity to challenge and question what happens in the working practice. The outcomes of this activity would be extremely positive, as it could develop skills in critical thinking, reflection, self-awareness and self-efficacy beliefs; improve care provided to patients
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70 through the development of new practical and theoretical knowledge; enhance professional development;
uncover pre-existing knowledge used without awareness; monitor knowledge and skills developed overtime; and finally it would provide the means to understand a theory, to assess its relevance and to understand the potential of practical implementation associated to it (Gillis, 2001; p. 57).
As mentioned, this overview provides only some examples of the type of activities that have been conducted in nursing education in order to stimulate the reflective practice of perspective and in-service professionals. This overview shows that the type of activity we are aiming at conducting in this context presents some elements of continuity with already existent practices in this field, while it brings new elements, as the use of collaborative writing and the possibility of sharing and discussing the experiences in a constructive and productive manner.